Client Intake Questionnaire

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Hello!

Welcome to Isaiah Forty's client intake questionnaire! This will help us get a sense of what you're looking for, and help us match you to the right person for you!

Every blessing,
Isaiah Forty Intake Team

PS Please be aware that the more restrictive your questionnaire is, the more it is likely that you will be on the waitlist for a longer period of time.

CRISIS CARE NOTICE

Please Note:

Isaiah Forty is not equipped to provide emergency services.

If you are in danger, please call 9-1-1.

First Name *

Last Name *

Email *

Can we send you information protected by confidentiality over email? *

Yes

Phone Number *

Can we leave voicemails for you with information protected by confidentiality? *

Yes

Gender *

Male

Female

Prefer not to say

What city and province/state do you live in? (e.g. Chicago, IL) *

What country do you live in? *

Canada

United States

Other:

What best describes your language restrictions? (If you can only do sessions in a language that is neither English or French, use the "Other" field) *

I prefer sessions in English

I would do English, but I prefer sessions in French

I would only do sessions in French

Other:

Which best describes your feelings about the gender of your provider? *

I don't have a preference on gender

I prefer a man, but I would see a woman

I would only see a man

I prefer a woman, but I would see a man

I would only see a woman

What best describes your feelings about the location of your session? *

I would only do in-person sessions

I would prefer in-person sessions, but I'm willing to do online sessions

I would prefer online sessions, but I'm willing to do in-person sessions

I would only do online sessions

What service are you interested in? *

Psychotherapy

Pastoral Counselling

Either a Psychotherapy or a Pastoral Counselling

Spiritual Formation Coaching

What best describes your feelings about your provider's relationship to insurance? (Directors and Coaches do not provide this option.) *

I don't have a preference on insurance

I would prefer someone who can give me a receipt for my insurance

I would only see someone who can give me a receipt for my insurance

What best describes your expectations for the number of clients in the session? Note that multi-client sessions adds $20 to the standard fee.

These would be individual sessions

These would be multi-client sessions (e.g. couples counselling)

Clear selection

What best describes the presence of minors in your session?

There would be no minors

There would be minors, age(s) less than 12 years old

There would be minors, age(s) 13 to 15 years old

There would be minors, age(s) 16+ years old

Describe your situation.

How did you hear about us?

Submit

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